Client Form

Client Form

Welcome to Oceana Veterinary Clinic and White Lake Animal Clinic!
Client Information
I am a:

Current clientNew Client
Full Name*

First NameLast Name
Spouse/Co-owner Name

First NameLast Name
Email Address*
example@example.com
Primary Phone Number*
Please enter a valid phone number.
Secondary Phone Number
Please enter a valid phone number.
Emergency Phone Number
Please enter a valid phone number.
Emergency Contact Name

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
How did you hear about us:*

Sign/Drive byFacebookInternet/WebsitePersonal RecommendationOther
If a personal recommendation, who may we thank? First Name Last Name
Previous Veterinarian Information

Please provide us with consent to request your pet(s) previous medical records, which will enable us to provide the best care possible.
Name of Previous Veterinary Facility
Previous Veterinarian's Phone Number
Please enter a valid phone number.
CONSENT TO REQUEST RECORDS: I hereby give consent to Horton Veterinary Services (DBA Oceana Veterinary Clinic and White Lake Animal Clinic) to request medical records for the pet(s) listed below.

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Pet Information
1st Pet's Name*
Type of Pet*

DogCat
Breed*
Age*
Gender*

Male IntactMale NeuteredFemale IntactFemale Spayed
Medical History

Please provide any relevant medical history for your pet.
Vaccination Record

Cancelof
Medical Conditions
2nd Pet's Name
Type of Pet

DogCat
Breed
Age
Gender

Male IntactMale NeuteredFemale IntactFemale Spayed
Medical History

Please provide any relevant medical history for your pet.
Vaccination Record

Cancelof
Medical Conditions
3rd Pet's Name
Type of Pet

DogCat
Breed
Age
Gender

Male IntactMale NeuteredFemale IntactFemale Spayed
Medical History

Please provide any relevant medical history for your pet.
Vaccination Record

Cancelof
Medical Conditions
Preferred Appointment Location

Oceana Veterinary Clinic - New Era, MIWhite Lake Animal Clinic - Montague, MI
Preferred Payment Method*

Credit/Debit CardCashCheckPet Insurance www.pawlicyadvisor.comCare Credit www.carecredit.comScratch Pay www.scratchpay.com
Additional Comments
AUTHORIZATION: I hereby authorize the veterinarian to examine, prescribe for, or treat the above-described pet(s). I understand that any medical or surgical procedure is attended by some risk and it is not possible to guarantee the outcome of any such procedure. I assume responsibility of all charges incurred in the care of the above-described pet(s). I also understand that these charges will be paid at the time of services or release of a hospitalized pet. I understand that a deposit may be required prior to surgical treatment or hospitalization. I also understand that unpaid balances will incur a monthly financing fee of $5.00 or 2.5% of the monthly balance due. I understand that after 90 days, any unpaid balances are subject to a 35% collection fee and services for my pet(s) may be terminated. *

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PICTURE USE CONSENT: Oceana Veterinary Clinic and White Lake Animal Clinic loves making pets Facebook/Instagram famous! Please give us permission to share your pet(s)' image and story on social media, our website and other marketing materials with your signature below. Your personal information will never be shared.

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Client Form

Client Information

Previous Veterinarian Information

Pet Information

Medical History

Medical History

Medical History